On 23 October 2012, the Wilson Center Maternal Health Initiative convened this dialogue, in partnership with the Maternal Health Task Force (MHTF) and the United Nations Population Fund (UNFPA).
“We know maternal health medicines are safe, we know they’re effective, we know they’re essential to keeping women healthy throughout pregnancy and childbirth,” said Kristy Kade at the Wilson Center on October 23. But lack of supply, poor quality and misuse means they do not always help the women who need them.
Kade is the author of the PATH report Safeguarding Pregnant Women with Essential Medicines: A Global Agenda to Improve Quality and Access, which takes on this challenge. She was joined by Deborah Armbruster and Rachel Wilson from PATH; Ann Starrs of Family Care International; Jagdish Udpadhyay from the United Nations Population Fund (UNFPA) and Dr. Kennedy Chibwe from the United States Pharmacopeial Convention.
They spoke specifically about a core group of medicines – magnesium sulfate, oxytocin and misoprostol – which, according to a new UN report, could save 70,000 lives within five years if they were made more widely available.
Magnesium sulfate is used to treat pre-eclampsia, a dangerous complication in pregnancy that can lead to seizures and sometimes death if left untreated. Oxytocin and misoprostol are both used to treat postpartum hemorrhaging.
Data, Data, Data
Though physical health infrastructure often gets more attention, “there’s very little a health worker can actually do when their supply cabinets are bare,” said Kade. Part of the challenge is that it’s difficult to advocate for increased supply without accurate statistics about current usage. “Unlike family planning commodities, for example, we have very little understanding of the actual number of women for whom essential maternal health medicines are not available,” Kade said.
To help gather this information and determine a course of action, PATH organized five policy meetings (including one here at the Wilson Center) this year with 130 stakeholders in maternal health participating, including ministers of health and members of non-governmental organizations. The results of these meetings were synthesized in the report.
Overall, there was a great deal of consensus about what needs to be done, with several main areas highlighted:
- Increase data gathering and tracking to help supply meet demand;
- Improve existing supply chains by taking advantage of “cold chains,” which help maintain critical refrigeration for certain drugs and vaccines;
- Make medicines easier to use by simplifying packaging and dosing regimens;
- Improve the quality and control of manufactured medicine; and
- Reduce misuse of existing supplies, like using oxytocin to augment labor instead of to reduce postpartum hemorrhage.
Information and Innovation
Jagdish Udpadhyay agreed that more data is needed to affectively address stubbornly high maternal mortality numbers in some parts of the world. But he stressed that simply providing medicine is not sufficient; without culturally sensitive education, products may go unused.
“We have to understand the culture, why people don’t take [medicines],” he said. “We have to understand the country context, we have to understand the cultural context, we have to understand the health-seeking behavior to be effective.”
He also spoke about the need for innovation, especially in delivering medicines to hard-to-reach places. One challenge that has changed little over the past 25 years at UNFPA is the unavailability of refrigeration in remote areas of developing countries. Oxytocin requires refrigeration and can thus be difficult to administer in developing countries. “It doesn’t cost that much to have temperature control,” he said. “What we need is a more consolidated effort, and media and all of you need to talk [about] it more loudly.”
Another way to increase the effectiveness of existing interventions while simultaneously decreasing cost is by integrating maternal health with other sectors. Udpadhyay sees great potential in combining maternal health programs with family planning as a cost-effective way to reach essentially the same populations.
Quality Over Quantity
“I originally come from Zambia, and I know what it means for someone not to get the right medicine and the impact on families. So that’s something that really drives me,” said Dr. Kennedy Chibwe. His experience has been one where quality is the challenge, not quantity. Maternal health medicines are prevalent and inexpensive, “but in most cases they’re either counterfeit or substandard,” he said.
To remedy this problem, Chibwe suggested creating and strengthening regulatory agencies. He gave an example from his work in Liberia, where he found that “80 percent of antimalarials had no active ingredients.” Unfortunately, this was not illegal at the time, so no one was prosecuted for selling these counterfeit medicines. Since the people buying these medicines often have little money to spare, the health and financial consequences of these counterfeits can be severe.
Even those medicines which are not counterfeit can be of poor quality. Chibwe recommended manufacturers be required to meet minimum “good manufacturing practices” (GMP). “And it’s not a separate GMP for third world and the developed world – no, it’s the same standard,” he said.
“If you don’t have a good product, you might as well just be distributing candy.”
Evaluating Training Efforts
“I think this is probably where we fall down with training, is that we don’t evaluate well enough,” said Deborah Armbruster. “Are we actually changing performance? Are we changing the behavior of providers?”
Sometimes practitioners are not being taught the behavior that can best impact their effectiveness, she said. For example, clinicians are often not taught how to properly store medicines, so those which require refrigeration like oxytocin lose their potency. Other times, inserts in drug packages are not printed in the local language.
“Behavior change and behavior change methodology is not sexy for clinicians,” she said. “They like training.” But when training is provided, it’s important to assess that health care providers are actually practicing the techniques they have been provided with, she said.
Whether a program change is related to training, medicine distribution, or cash incentives, above all, the focus needs to be on quality of care with an eye on results, Armbruster said. “There’s a lot of things we could be doing that we’re not initiating.”
Developments on Misoprostol
There have been “tremendous changes and tremendous progress with the drug misoprostol over the last few years,” said Ann Starrs, which may “provide a real opportunity” for improving maternal health outcomes. The drug – a pill that stops postpartum hemorrhaging and can be easily stored and administered – has been endorsed by both the World Health Organization and the International Federation of Gynecology and Obstetrics, which both issue guidelines for its use.
However there are still some barriers to more widespread use. One concern is that providing misoprostol directly to women may prevent them from giving birth in health facilities with an attendant. “There isn’t any evidence that that is happening,” said Starrs, pointing to pilot studies which suggest emphasizing birth planning along with drug distribution could actually increase the number of deliveries in health facilities.
Another concern is that it will be misused to induce labor or as an abortive agent. “We need to acknowledge that that’s going to happen,” Starrs said, but the benefits of misoprostol are too great to prevent community-based distribution, which can have a “tremendous impact” on reducing post-partum hemorrhage.
Looking Back to Move Forward
Important lessons can be learned from other drug distribution movements, like those for family planning and HIV/AIDS, said the panelists. In both cases, country- and community-based distribution systems made program implementation more successful than predicted by the medical community.
For HIV/AIDS in particular, the medical community believed that complex dosing regimens would lead to misuse of anti-retrovirals (ARVs), which would lead to “huge problems,” said Starrs. But the relative success of ARV distribution demonstrates that maternal health medicines “can be used appropriately and effectively at the community level.”
Overwhelmingly, the panelists urged more general awareness of the challenges and opportunities of maternal mortality and health issues. “People that shouldn’t be dying are dying,” said Chibwe.
“We know the problem, we know the solution,” said Udpadhyay. “What we need to do is scale up and work hard.”
Sources: PATH, U.S. Department of Health and Human Services, World Health Organization.
- Kristy Kade
- Deborah Armbruster
- Rachel Wilson
- Ann Starrs
- Jagdish Udpadhyay (view presentation)
- Dr. Kennedy Chibwe